Errors in antibiotic transitions between hospital and nursing home: How often do they occur?

Antimicrobial Stewardship at Transitions of Care to Outpatient Settings: Synopsis and Strategies

Inappropriate antibiotic use and associated consequences, including pathogen resistance and Clostridioides difficile infection, continue to serve as significant threats in the United States, with increasing incidence in the community setting. While much attention has been granted towards antimicrobial stewardship in acute care settings, the transition to the outpatient setting represents a significant yet overlooked area to target optimized antimicrobial utilization. In this article, we highlight notable areas for improved practices and present an interventional approach to stewardship tactics with a framework of disease, drug, dose, and duration. In doing so, we review current evidence regarding stewardship strategies at transitional settings, including diagnostic guidance, technological clinical support, and behavioral and educational approaches for both providers and patients.

Preventing healthcare-related infections among older adults: a focus on cross-transmission of antibiotic-resistant bacteria

INTRODUCTION

Older individuals (i.e. age ≥65 years) are at increased risk for development of infections including those due to antimicrobial-resistant bacteria, and transmission may occur between institutional and community settings.

AREAS COVERED

This article reviews infections in older individuals with a specific focus on healthcare-related and antimicrobial resistant infections. A structured narrative review was performed to identify articles published in English since 2010. Themes included defining the scope of the problem, establishing characteristics of older individuals that impact the burden of resistant infections, and interventions aimed at minimizing their impact.

EXPERT OPINION

Older individuals suffer a high burden of illness related to antimicrobial resistant infections. Individuals with chronic illnesses, frailty, and residents of nursing homes are at highest risk. Clinical trials have shown that antimicrobial stewardship interventions may reduce antibiotic use in nursing homes without compromising safety. Antimicrobial resistant bacteria are prevalent among nursing home residents, and bundled infection prevention and control interventions can reduce their transmission. Transmission of antimicrobial resistant bacteria occurs among older adults across hospital and institutional settings, which may further spread to the community. The burden of infections in older adults is expected to increase in the coming years and represents a healthcare and research priority.

Association of Exposure to High-risk Antibiotics in Acute Care Hospitals With Multidrug-Resistant Organism Burden in Nursing Homes

IMPORTANCE

Little is known about the contribution of hospital antibiotic prescribing to multidrug-resistant organism (MDRO) burden in nursing homes (NHs).

OBJECTIVES

To characterize antibiotic exposures across the NH patient's health care continuum (preceding health care exposure and NH stay) and to investigate whether recent antibiotic exposure is associated with MDRO colonization and room environment contamination at NH study enrollment.

DESIGN, SETTING, AND PARTICIPANTS

This is a secondary analysis of a prospective cohort study (conducted from 2013-2016) that enrolled NH patients and followed them up for as long as 6 months. The study was conducted in 6 NHs in Michigan among NH patients who were enrolled within 14 days of admission. Clinical metadata abstraction, multi-anatomical site screening, and room environment surveillance for MDROs were conducted at each study visit. Data were analyzed between May 2019 and November 2021.

EXPOSURES

Antibiotic data were abstracted from NH electronic medical records by trained research staff and characterized by class, route, indication, location of therapy initiation, risk for Clostridioides difficile infection (C diffogenic agents), and 2019 World Health Organization Access, Watch, and Reserve (AWARE) antibiotic stewardship framework categories.

MAIN OUTCOMES AND MEASURES

The primary outcomes were MDRO colonization and MDRO room environment contamination at NH study enrollment, measured using standard microbiology methods. Multivariable logistic regression was used to identify whether antibiotic exposure within 60 days was associated with MDRO burden at NH study enrollment. Additionally, antibiotic exposure data were characterized using descriptive statistics.

RESULTS

A total of 642 patients were included (mean [SD] age, 74.7 [12.2] years; 369 [57.5%] women; 402 [62.6%] White; median [IQR] NH days to enrollment, 6.0 [3.0-7.0]). Of these, 422 (65.7%) received 1191 antibiotic exposures: 368 (57.3%) received 971 hospital-associated prescriptions, and 119 (18.5%) received 198 NH-associated prescriptions. Overall, 283 patients (44.1%) received at least 1 C diffogenic agent, and 322 (50.2%) received at least 1 high-risk WHO AWARE antibiotic (watch or reserve agent). More than half of NH patients (364 [56.7%]) and room environments (437 [68.1%]) had MDRO-positive results at enrollment. In multivariable analysis, recent antibiotic exposure was positively associated with baseline MDRO colonization (odds ratio [OR], 1.70; 95% CI, 1.22-2.38) and MDRO environmental contamination (OR, 1.67; 95% CI, 1.17-2.39). Exploratory stratification by C diffogenic agent exposure increased the effect size (MDRO colonization: OR, 1.99; 95% CI, 1.33-2.96; MDRO environmental contamination: OR, 1.86; 95% CI, 1.24-2.79). Likewise, exploratory stratification by exposure to high-risk WHO AWARE antibiotics increased the effect size (MDRO colonization: OR, 2.32; 95% CI, 1.61-3.36; MDRO environmental contamination: OR, 1.86; 95% CI, 1.26-2.75).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that high-risk, hospital-based antibiotics are a potentially high-value target to reduce MDROs in postacute care NHs. This study underscores the potential utility of integrated hospital and NH stewardship programming on regional MDRO epidemiology.

Interprofessional and Intraprofessional Communication about Older People's Medications across Transitions of Care

Communication breakdowns contribute to medication incidents involving older people across transitions of care. The purpose of this paper is to examine how interprofessional and intraprofessional communication occurs in managing older patients' medications across transitions of care in acute and geriatric rehabilitation settings. An ethnographic design was used with semi-structured interviews, observations and focus groups undertaken in an acute tertiary referral hospital and a geriatric rehabilitation facility. Communication to manage medications was influenced by the clinical context comprising the transferring setting (preparing for transfer), receiving setting (setting after transfer) and 'real-time' (simultaneous communication). Three themes reflected these clinical contexts: dissemination of medication information, safe continuation of medications and barriers to collaborative communication. In transferring settings, nurses and pharmacists anticipated communication breakdowns and initiated additional communication activities to ensure safe information transfer. In receiving settings, all health professionals contributed to facilitating safe continuation of medications. Although health professionals of different disciplines sometimes communicated with each other, communication mostly occurred between health professionals of the same discipline. Lack of communication with pharmacists occurred despite all health professionals acknowledging their important role. Greater levels of proactive preparation by health professionals prior to transfers would reduce opportunities for errors relating to continuation of medications.

[Inadequate antibiotic prescribing and areas for improvement]

Inadequate antibiotic prescribing has been observed in many settings both in hospitals as well as in primary care. Most often there is uncertainty about the indication for antibiotic treatment itself, prescribers are reluctant to deescalate, and therapy duration is too long which results most often in overprescribing. The burden of overprescribing is difficult to estimate, but many studies in the hospital setting report a rate of approximately 30 % of inadequate prescribing - with wide variation. Over- but also underprescribing of antimicrobial agents is a serious patient safety issue that needs to be addressed in specific programmes at different levels of the healthcare system. Interventional studies have shown that programmes implementing or intensifying audit and feedback with clinical reevaluation by experts can be very efficient to reduce inadequate prescribing.